Same or Similar Chart - JA DME

Replacement

The definition of replacement is found in CMS Internet Only Manual (IOM), Publication 100-02, Benefit Policy Manual, Chapter 15, Section 110.2.C. That section generally defines replacement as the provision of an entirely identical or nearly identical item when the original item is lost, stolen, or irreparably damaged. Further direction on replacement is included in the Standard Documentation Requirements Article (A55426) on the CMS website.

Replacement of items due to irreparable wear takes into consideration the Reasonable Useful Lifetime (RUL) of the item. The RUL for durable medical equipment (DME) is determined through program instructions. In the absence of program instructions, Medicare Administrative Contractors (MACS) may determine the RUL of equipment, but in no case can it be less than 5 years.

• Computation of the RUL is based on when the equipment is delivered to the beneficiary, not the age of the equipment.
• Replacement due to wear is not covered during the RUL of the equipment.
• During the RUL, Medicare does cover repair up to the cost of replacement (but not actual replacement) for medically necessary equipment owned by the beneficiary.

Not Covered

The items listed below are not covered for replacement.

• Items that require frequent and substantial servicing
• Inexpensive or routinely purchased items which are being rented

Replacement of Prosthetics - There are special rules for the replacement of artificial arms, lower limbs, and eyes. You can find more information on the Replacement webpage.

Is the Item Same or Similar?

Prior to replacing an item, and to gain the necessary information required for determining whether same or similar is affected, these questions should be considered:

• Has there been a change in the beneficiary's medical condition that supports the need for a same or similar type of item?
• Has the original item been lost, stolen, or irreparably damaged?
  • Answering these questions will help determine whether an Advance Beneficiary Notice of Noncoverage (ABN) should be obtained
• Has the beneficiary had a same or similar item?
  • If he/she has not had a same or similar item, bill claim without obtaining an ABN (no ABN necessary)
  • If he/she has had a same or similar item, determine if item has reached its RUL
  • If RUL reached, bill claim without ABN (no ABN necessary)
  • If item has not reached RUL, obtain an ABN and bill claim with applicable modifier

Verification options include:

1. Ask beneficiary
2. Check via Noridian Interactive Voice Response (IVR)
3. Access such information within Noridian Medicare Portal (NMP)

If there is any reason to believe that a beneficiary may have obtained a same or similar item outside of Jurisdiction A, check with the other jurisdictions (B, C, and D) as well.

• Same or Similar: How to Avoid Denial
• Same or Similar Denials
• Same or Similar and Advance Beneficiary Notice of Noncoverage (ABN) Documentation
• Reasonable Useful Lifetime Clarification
• Reasonable Useful Lifetime and Duplicate Items - Billing Reminder

Same or Similar Chart

The list is NOT all inclusive and that while every effort is made to keep it current, there may be relationships that might trigger a denial that are not listed.

Note: Some HCPCS codes may be updated when a temporary code is deleted. If the deleted code is not searched for during a same or similar inquiry, it could result in a denial. For instance, the deletion of code K0554 and the introduction of code E2103 exemplify this need for thorough searches. Ensure that all relevant HCPCS codes are entered when conducting searches in the NMP to avoid potential denials.